Fatal case of Heartland Virus


The Heartland virus (HRTV) is an emerging tick-borne illness which can be acquired through the bite of an infected Lone Star tick. The virus was first reported in 2009 in Missouri. Since then, it has spread to other states including Kansas, Oklahoma, Arkansas, Tennessee, Kentucky, Indiana, Illinois, Iowa, Georgia, Pennsylvania, New York, and North Carolina, according to the Centers for Disease Control and Prevention (CDC).

Now, investigators have identified the Heartland virus in the Maryland and Virginia region – an area where the virus is not widely recognized.

In their article “Fatal Case of Heartland Virus Disease Acquired in the Mid-Atlantic Region, United States,”¹ Liu and colleagues describe the fatal case of a man in his 60’s who acquired the Heartland virus in either Maryland or Virginia.

The man was admitted to the hospital in November 2021 with a fever, diarrhea, dyspnea, myalgias, and malaise which had been ongoing for 5 days. He had a history of a splenectomy, hypertension, remote trauma, coronary artery disease, and hypertension.

The patient did not recall a tick bite and did not have an erythema migrans rash.

“The range of [Heartland virus] could be expanding in the United States.”

“An arboviral disease was the leading diagnostic consideration, but limited availability of commercial diagnostic testing for tickborne diseases delayed diagnosis,” wrote Liu et al.

The man was treated clinically for a tick-borne infection with doxycycline.

“Two days later, on day 7 after symptom onset, the patient returned to the emergency department with confusion, an unsteady gait, and new fecal and urinary incontinence,” according to the authors.

He subsequently developed encephalopathy, low sodium, abnormal liver function tests, and fatigue.

“He had acute respiratory failure, renal failure, and a cardiac arrest. He was transitioned to comfort care and died on day 13 after symptom onset,” wrote Liu et al.

An autopsy revealed that the heart, spleen, kidney, and liver samples were positive for Heartland virus.

The Virginia Department of Health conducted a drag of the man’s property and found 193 Lone Star ticks. However, none of the ticks contained HRTV.

Tick-borne diseases identified by the CDC, as of 2/26/23.²

  • Anaplasmosis
  • Babesiosis
  • Borrelia mayonii
  • Borrelia miyamotoi
  • Bourbon virus
  • Colorado tick fever
  • Ehrlichiosis
  • Heartland virus
  • Lyme disease
  • Powassan disease
  • Rocky Mountain spotted fever (RMSF)
  • STARI (Southern tick-associated rash illness)
  • Tick-borne relapsing fever (TBRF)
  • Tularemia
  • 364D rickettsiosis (Rickettsia phillipi, proposed)
  1. Liu S, Kannan S, Meeks M, et al. Fatal Case of Heartland Virus Disease Acquired in the Mid-Atlantic Region, United States. Emerg Infect Dis. Feb 23 2023;29(5)doi:10.3201/eid2905.221488
  2. Diseases Transmitted by Ticks. Centers for Disease Control and Prevention. https://www.cdc.gov/ticks/diseases/index.html Last accessed 2/26/23.

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